Tag Archives: chest tube

General

Chest X-Ray After Chest Tube: Why Do We Do It?

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More dogma, or is it actually useful? Any time a chest tube (tube thoracostomy) is inserted, we automatically order a chest x-ray. Even the ATLS course recommends obtaining an image after placement. But anything we do “automatically” is grounds for critical analysis to see if there is a valid reason for doing it. 

A South African group looked at the utility of this practice retrospectively in 1004 of their patients. They place 1042 tubes. Here are the factoids:

  • Patients were included if they had at least one chest x-ray obtained after insertion
  • Patients were grouped as follows: Group A (10%) had the tube inserted on clinical grounds with no pre-insertion x-ray (e.g. tension pneumothorax). Group B (19%) had a chest x-ray before and had ongoing clinical concerns after insertion. Group C (71%) had a chest-xray before and no ongoing concerns.
  • 75% of injuries were penetrating (75% stab, 25% GSW), 25% were blunt
  • Group A (insertion with pre-x-ray): 9% had post-insertion findings that prompted a management change (kinked, not inserted far enough)
  • Group B (ongoing clinical concerns): 58% required a management change based on the post-x-ray. 33% were subcutaneous or not inserted far enough (!!)
  • Group C (no ongoing clinical concerns): 32 of 710 (5%) required a management change, usually because the tube was too deep

The authors concluded that if there are no clinical concerns (tube functioning, no clinical symptoms) after insertion, then a chest x-ray is not necessary. 

Bottom line: But I disagree with the authors! Even with no obvious clinical concerns, the tube may not be functioning for a variety of reasons. Hopefully, this fact would then be discovered the next day when another x-ray is obtained. But this delays the usual progression toward removing the tube promptly by at least one day. It increases hospital stay, as well as the likelihood of infection or other hospital-associated complication. A chest x-ray is cheap compared to a day in the hospital, which would potentially happen in 5% of these patients. I recommend that we continue to obtain a simple one-view chest x-ray after tube insertion.

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General

Autotransfusing Blood Lost Through The Chest Tube

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Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

The authors found that:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

image

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

General

Autotransfusing Blood Lost Through The Chest Tube

Leave a comment

Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion. 

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

The authors found that:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

image

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

General

Pneumothorax: How Big Is Too Big?

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One of the big unanswered questions in the management of pneumothorax is, how big is too big? At what size is a chest tube of some type mandatory? 

The problem is that we just don’t have any good data. Seems like a simple problem, right? Unfortunately, it’s not. A pneumothorax is a three dimensional collection that surrounds the lung in very random ways. All we had to detect and “measure” them for decades was the lowly chest x-ray. Unfortunately, this is a 2D shadow picture that does not allow us to accurately estimate the size.

A few old papers exist that tried to quantify pneumothorax, but they are of no use now that we have chest CT. Unfortunately this new technology has drawbacks, as well. First, it’s just a stack of 2D images that our minds assemble into a 3D mental model, so it’s still difficult to quantify the air. And second, you shouldn’t be getting a chest CT just to diagnose pneumothorax. In blunt trauma, it’s really just for checking the thoracic aorta for injury.

So we’re left with the original question, and there are three answers. If there is any physiologic compromise (hypoxia, tachypnea, anxiety), then the chest should be drained. If the pneumothorax is enlarging over serial chest x-rays, then it should be drained before it causes physiologic change. And finally, if there is concern that it is so large that it will take too long to absorb, especially in older patients with comorbidities, a chest drain should be inserted. This is a somewhat soft indication, however.

Bottom line: The three reasons above are the usual answers to the question, “how big is too big?” For me, once the pneumothorax pushes the lung 1-2 cm away from the chest wall from apex to base, it’s time for a tube.

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Pigtail Cathers Instead Of Chest Tubes?

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I reviewed this abstract a few months ago, and now I’ve had the opportunity to hear it and see the data. Here’s an update on whether this is worthwhile..

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

There were a few questions regarding blinding of the pain scale raters, but other than the small sample size, the study was nicely done.

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

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Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.